A trial of methadone tapering schedules in pediatric intensive care unit patients exposed to prolonged sedative infusions*

Bowens, Cindy Darnell; Thompson, Jennifer A.; Thompson, Marita; Breitzka, Robin L.; Thompson, Debbie Gearner; Sheeran, Paul

doi:10.1097/pcc.0b013e3181fe38f5

Cited by 51 publications

(100 citation statements)

References 47 publications

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“…1,4,8,16,17,25–35 Subjects with longer PICU or hospital lengths of stay, 8,29 more ventilator days, 8,29 and longer ECMO therapy 4,28 were more likely to experience IWS. In one paper, subjects in a randomized trial of methadone-facilitated weaning were more likely to experience treatment failure with longer PICU lengths of stay, particularly after receiving fentanyl for ≥9 days.…”

Section: Resultsmentioning

confidence: 99%

“…In one paper, subjects in a randomized trial of methadone-facilitated weaning were more likely to experience treatment failure with longer PICU lengths of stay, particularly after receiving fentanyl for ≥9 days. 29 In two small studies, subjects experiencing IWS received at least 10 days of opioid or benzodiazepine therapy. 34,35 …”

Section: Resultsmentioning

confidence: 99%

“…Many studies evaluating IWS symptoms attributable to either opioids or benzodiazepines reported dosage associations: 1,8,12,13,17,20,21,23,29–31,34,35,39 one found moderate correlations with opioid dose alone, 31 and four with both opioid and benzodiazepine dose. 1,13,30,36 The remaining studies reported differences between groups with and without IWS in cumulative opioid and/or benzodiazepine doses, 8,12,17,23,29,39 or had too few subjects for statistical analysis.…”

Section: Resultsmentioning

confidence: 99%

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Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients

Best

Boullata

Curley³

2015

Pediatric Critical Care Medicine

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Objective Analgesia and sedation are common therapies in pediatric critical care, and rapid titration of these medications is associated with iatrogenic withdrawal syndrome (IWS). We performed a systematic review of the literature to identify all common and salient risk factors associated with IWS and build a conceptual model of IWS risk in critically ill pediatric patients. Data sources Multiple databases, including PubMed/Medline, EMBASE, CINAHL, and the Cochrane Central Registry of Clinical Trials were searched using relevant terms from January 1, 1980 to August 1, 2014. Study selection Articles were included if they were published in English and discussed IWS following either opioid or benzodiazepine therapy in children in acute or intensive care settings. Articles were excluded if subjects were neonates born to opioid- or benzodiazepine-dependent mothers, children diagnosed as substance abusers, or subjects with cancer-related pain; if data about opioid or benzodiazepine treatment were not specified; or if primary data were not reported. Data extraction and synthesis In total 1395 papers were evaluated, 33 of which met the inclusion criteria. To facilitate analysis, all opioid and/or benzodiazepine doses were converted to morphine or midazolam equivalents, respectively. A table of evidence was developed for qualitative analysis of common themes, providing a framework for the construction of a conceptual model. The strongest risk factors associated with IWS include duration of therapy and cumulative dose. Additionally, evidence exists linking patient, process and system factors in the development of IWS. Findings Most papers were prospective observational or interventional studies. Conclusions Given the state of existing evidence, well-designed prospective studies are required to better characterize IWS in critically ill pediatric patients. This review provides data to support the construction of a conceptual model of IWS risk that, if supported, could be useful in guiding future research.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients

Best

Boullata

Curley³

2015

Pediatric Critical Care Medicine

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show abstract

“…60 Bowens et al compared the weaning of opioids with low and high doses of methadone, showing no difference between the two approaches. 61 Other studies demonstrated the implementation of a protocol for the management of abstinence syndrome reduces the time and dosage of those drugs, while the WAT-1 scale has a good performance evaluating abstinence. [62][63][64][65][66] Fernandez-Carrión et al showed that reductions of 10% in the doses of methadone every day implied in no increase in the incidence of signs and symptoms of abstinence, needs of morphine rescue therapy, or excess sedation.…”

Section: Resultsmentioning

confidence: 99%

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Motta

Luglio²,

Delgado

et al. 2016

Rev. Assoc. Med. Bras.

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Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.

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“…Weaning strategies ranging from 10 days to several months have been evaluated in observational (retrospective and prospective) studies (132–136). Two negative RCTs evaluated methadone weaning in 5 vs. 10 days (137) and a high- vs. low-dose methadone schedule in children (138). And while target drug levels for sedative and opioid dependence have been established for adults, they are lacking for children, as are PK data.…”

Section: Adverse Effectsmentioning

confidence: 99%

Sedation in Critically Ill Children with Respiratory Failure

Vet¹,

Kleiber²,

Ista³

et al. 2016

Front. Pediatr.

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This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.

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A trial of methadone tapering schedules in pediatric intensive care unit patients exposed to prolonged sedative infusions*

Cited by 51 publications

References 47 publications

Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients

Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Sedation in Critically Ill Children with Respiratory Failure

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